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Running head: INTEGRATIVE REVIEW

Integrative Review

Kasey Mitchell

Karen Mellott, PhD, RN

NUR 4322: Nursing Research

Bon Secours Memorial College of Nursing

April 21st, 2020

“I pledge”
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Abstract

Purpose: The purpose of this integrative review is to determine the effect of delayed cord

clamping versus early cord clamping on hemoglobin levels in infants.

Introduction and Background: The timing of umbilical cord clamping is crucial, as it may

provide positive benefits to the infant.

PICOT: In infants, what is the effect of delayed cord clamping versus early cord clamping on

hemoglobin levels during the first year of life?

Design and Search Methods: This integrative review collected research from multiple

databases which include PubMed, Academic Search Complete, and EBSCO Medline Complete.

Articles in this review were included based off specific criteria. The articles were then used to

determine the relationship among hemoglobin levels and the timing of umbilical cord clamping.

Results and Findings: Results from five articles utilized in this integrative review conclude that

infants who receive delayed cord clamping have significantly higher hemoglobin levels than

infants who receive early cord clamping. Additionally, one article from this integrative review

concludes that delayed cord clamping significantly increases ferritin levels at eight months of

age.

Limitations: The most significant limitation in this integrative review is the inexperience of the

researcher. Another limitation, noted by the researcher, is the inconsistency of the time frames

among the intervention and control group in the five articles.

Implications: The implementation of delayed cord clamping has the ability to significantly

increase hemoglobin levels among infants.

Recommendations: The researcher recommends further research to address additional fetal and

maternal outcomes in relationship to delayed cord clamping.

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Integrative Review

The purpose of this integrative review is to compare the intervention of delayed cord

clamping (DCC) versus early cord clamping (ECC) on hemoglobin levels in infants. Throughout

the world, the ideal timing for umbilical cord clamping following delivery has been debated

among healthcare professionals (Mohammad, Tailakh, Fram, & Creedy, 2019). Within different

institutions, the definitions of DCC and ECC may vary depending upon the time frame that the

institution sets.

The timing of umbilical cord clamping is important, as it can provide many benefits to

the infant. DCC has been associated with favorable outcomes in both pre-term and term infants.

This intervention is known to increase the level of hemoglobin at birth and improve iron storage

during the first several months in term infants (Abbas, Elboghdady, & Mohammed, 2019). In

pre-term infants, DCC has been shown to improve the circulation during the transitional phase,

increase the red blood cell volume which decreases the need for blood transfusions and decreases

the incidence of necrotizing enterocolitis (Abbas et al., 2019). In addition, the World Health

Organization, the National Institute for Health and Care Excellence, the International Liaison

Committee on Resuscitation, the American Heart Association, and the American Academy of

Pediatrics recommends delaying cord clamping in all births (Mohammad et al., 2019). The

purpose of this review is to analyze and discuss the findings of published data related to the

researchers PICOT question: “In infants, what is the effect of delayed cord clamping versus early

cord clamping on hemoglobin levels during the first year of life?”.

Design/Search Methods

The researcher utilized many search engines such as PubMed, Academic Search

Complete, and EBSCO Medline Complete to locate the published data. The search words were
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‘delayed cord clamping’, ‘early cord clamping’, ‘umbilical cord clamping’, with secondary

search words being ‘hemoglobin’, and ‘anemia’. This search yielded 2,630 results. The results

were then filtered by a five-year time frame, English language, peer-review, and relevance to the

researchers PICOT question: “In infants, what is the effect of delayed cord clamping versus early

cord clamping on hemoglobin levels during the first year of life?”.

Each article must have included all aspects of the researchers PICOT question. In

addition, the articles must have been well written, organized and ethically approved. Further

inclusion criteria for the articles are: quantitative nature, infant population, and findings within

the first year of life. The articles were screened based on this researcher’s inclusion criteria and

relevance to the PICOT question. Articles that did not meet the researcher’s inclusion criteria

were excluded. The final number of articles that met the inclusion criteria, set by the researcher,

were five quantitative studies (Abbas et al., 2019; Ertekin et al., 2015; Kc et al., 2017;

Mohammad et al., 2019; Nouraie, Amir Ali Akbari, Vameghi, & Akbarzadeh Baghban, 2019).

Findings/Results

The findings and results of the five reviewed studies suggest that delayed cord clamping

significantly increases hemoglobin levels in infants (Abbas et al., 2019; Ertekin et al., 2015; Kc

et al., 2017; Mohammad et al., 2019; Nouraie et al., 2019). Appendix 1 provides a brief summary

of the five research articles that the researcher used. This review is structured based on similar

categories found among infants who received delayed cord clamping: hemoglobin levels,

bilirubin levels, and ferritin levels.

Increased Hemoglobin Levels

All five research articles utilize quantitative studies to determine the effect of delayed

cord clamping on hemoglobin levels (Abbas et al., 2019; Ertekin et al., 2015; Kc et al., 2017;
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Mohammad et al., 2019; Nouraie et al., 2019). For newborns, the normal hemoglobin range is

12-24 grams(g) per deciliter(dL) (Pagana & Pagana, 2018, p. 252). In infants two months to one

year, the normal hemoglobin range is “9.5-17 g/dL” (Pagana & Pagana, 2018, p.252). It is

important to note that the normal hemoglobin range may change depending upon the institution

and the age of the individual.

The purpose of the study, conducted by Abbas et al. (2019), is to compare hemoglobin

levels, hematocrit levels, and bilirubin levels in the ECC group versus DCC group in pre-term

births. For this study, the researcher defined pre-term births as any infant delivered before 37

weeks of gestation (Abbas et al., 2019). This prospective randomized control study sampled 100

pregnant patients, that were equally separated into the delayed cord clamping group or the early

cord clamping group, at Al-Azhar University Maternity Hospital in Egypt (Abbas et al., 2019).

Hemoglobin and hematocrit data were analyzed and collected within four hours of life. Serum

bilirubin data was analyzed and collected at 12 hours of life, day three, and day seven of life.

According to Abbas et al. (2019), the data was analyzed utilizing the Statistical Program for

Social Science (SPSS) version 20.0, where the following tests were completed: t-test, Mann

Whitney U test, Chi-square ( x 2) test, and Pearson’s correlation coefficient (r) test. The study

concluded that there was a statistically significant difference in the hemoglobin and hematocrit

levels among the two groups; where the DCC group had higher levels of hemoglobin than the

early cord clamping group (Abbas et al., 2019).

The main purpose of the study conducted by Ertekin et al. (2015), is to compare levels of

hemoglobin and ferritin between the DCC group and the ECC group. Additionally, the

researcher analyzed bilirubin levels in infants who appeared jaundice. This is a significant

difference among the articles written by Abbas et al. (2019) and Mohammad et al. (2019), as
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they obtained bilirubin levels on all infants despite the incidence of jaundice. This prospective

case-control study sampled 150 infants, where 74 were placed in the ECC group and 76 were

placed in the DCC group, at Zeynep Kamil Maternity and Children’s Disease, Training and

Research Hospital in Turkey (Ertekin et al., 2015). Immediately following delivery, venous

blood was collected to analyze the hemoglobin and ferritin levels. Additionally, the same levels

were obtained again at two months of age. The data was analyzed utilizing SPSS version 16.0,

where the t-test and ( x 2) test were completed to compare the values of the two groups for

statistical significance (Ertekin et al., 2015). According to Ertekin et al. (2015), there were no

significant differences in hemoglobin and hematocrit levels among the two groups initially. This

initial finding differs from two other studies, Abbas et al. (2019) and Nouraie et al. (2019), as

they report a significant increase in hemoglobin levels immediately following birth. However, it

was noted that at two months of age, the DCC group had a significant higher level of hemoglobin

and hematocrit when compared to the ECC group (Ertekin et al., 2015). Additionally, Ertekin et

al. (2019) concluded that there was a significant statistical difference in the need for blood

transfusions among individuals in the ECC group. The need for a blood transfusion among

infants was not assessed in any other article which poses as a significant difference when

comparing the articles.

The purpose of the study conducted by Kc et al. (2017), was to compare the hemoglobin

levels, ferritin levels, and the incidence of iron-deficiency anemia between the DCC group and

the ECC group. This randomized clinical trial sampled 540 infants, where 270 where placed in

the DCC group and 270 were placed in the ECC group, at Paropakar Maternity and Women’s

Hospital in Nepal (Kc et al., 2017). A venous sample was collected at eight and 12 months of life

to analyze the levels of hemoglobin and ferritin. The levels of hemoglobin and ferritin can then
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be utilized to conclude if the patient is experiencing iron-deficiency anemia. This study

specifically stated that iron-deficiency anemia was to be diagnosed if the hemoglobin was less

than 11 g/dL and the ferritin was less than 12 micrograms per liter (Kc et al., 2017). Data was

analyzed with an unpaired two-tailed t test, Fisher exact test, Multivariate analysis of variance,

logistic region analysis, and SPSS version 22 (Kc et al., 2017). This study concluded that the

hemoglobin and ferritin levels were significantly higher in the DCC group (Kc et al., 2017).

Additionally, it was reported that the incidence of iron-deficiency anemia was significantly

higher among the ECC group (Kc et al., 2017).

The purpose of the study, conducted by Mohammad et al. (2019), is to compare

hemoglobin and bilirubin levels between the two groups – DCC and ECC. This quasi-

experimental design sampled 180 mothers, that were equally divided among the DCC group and

the ECC group, at Jordan University Hospital located in Jordan (Mohammad et al., 2019).

Hemoglobin and bilirubin levels were collected 12 hours following birth. In addition, the

bilirubin levels were collected again at day three of life. According to Mohammad et al. (2019),

the data was analyzed using the SPSS version 25 along with a t-test and a chi-square test. It was

concluded that DCC had a significantly positive effect on the hemoglobin levels after 12 hours of

birth (Mohammad et al., 2019).

In the final study, conducted by Nouraie et al. (2019), the author’s purpose is to compare

hemoglobin levels among the DCC group and the ECC group. This randomized clinical trial

sampled 400 pregnant women, where 200 were equally placed among the two groups, at a

hospital that was affiliated with Isfahan University of Medical Sciences and Health Sciences in

Iran (Nouraie et al., 2019). The venous sample was collected immediately following delivery to

analyze the hemoglobin level. According to Nouraie et al. (2019), the data was analyzed utilizing
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the SPSS version 19. The SPSS data analysis method serves a similarity among all five of the

research studies mentioned in this integrative review. This study concludes that the hemoglobin

level was significantly higher in the DCC group when compared to the ECC group (Nouraie et

al., 2019).

Bilirubin Levels

Three out of the five quantitative articles included in this integrative review compare

bilirubin levels among infants in the DCC group and the ECC group (Abbas et al. 2019; Ertekin

et al. 2015; Mohammad et al. 2019). According to Pagana and Pagana (2018), the normal range

of bilirubin in infants is “1.0-12.0 milligrams per deciliter” (p. 109). However, it is important to

note that the normal range of bilirubin may vary depending upon certain institutions.

The study, conducted by Abbas et al. (2019), bilirubin levels was compared to see if there

was a statistical difference among the DCC group and the ECC group. This prospective

randomized control study concluded that there was no statistical difference in bilirubin levels

among the two groups (Abbas et al., 2019).

In the study, conducted by Ertekin et al. (2015), bilirubin levels were assessed only when

the infant appeared jaundice and needing phototherapy. This is a significant difference among

the other two studies that were conducted by Abbas et al. (2019) and Mohammad et al. (2019).

This poses a significant limitation to this study, as it cannot properly conclude that delayed cord

clamping increases the risk of higher bilirubin levels. Ertekin et al. (2019), concluded that the

mean of the maximum bilirubin levels was higher among the DCC group than the ECC group.

This result is significantly different when compared to the two other studies conducted by Abbas

et al. (2019) and Mohammad et al. (2019).

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A study conducted by Mohammad et al. (2019), bilirubin levels were compared among

the DCC group and the ECC group to see if there was a significance difference. This quasi-

experimental design study concluded that there were no statistical significant differences in

bilirubin levels at 12 hours following delivery or at three days of life among the two groups

(Mohammad et al. 2019). These results are similar to the study conducted by Abbas et al. (2019),

as they both state that there is no statistical difference in bilirubin levels among DCC and ECC

groups.

Ferritin Levels

Two of the five articles included in this integrative review compare ferritin levels among

the DCC group and the ECC group (Ertekin et al. 2019; Kc et al. 2017). According to Pagana &

Pagana (2018), the normal range of ferritin levels for individuals up to 15 years old is “7-600

nanograms per milliliter” (p.211). It is imperative to note that these levels may change based

upon the institution. These two studies differ with their results; however, it may be related to the

difference in the time frame that the ferritin levels were obtained.

In the study, conducted by Ertekin et al. (2015), ferritin levels were compared among the

DCC group and the ECC group immediately following birth and at two months of age. This

prospective case-control study concluded that the ferritin levels were not significantly different

among the two groups at birth, nor at two months of age (Ertekin et al. 2015).

The study conducted by Kc et al. (2017), compared the ferritin levels at eight and 12

months of age. This randomized control trial reported that the ferritin levels were significantly

higher in the DCC when compared to the ECC group at eight months of age (Kc et al. 2017). At

12 months of age, this study reported that there were no differences in ferritin levels among the

two groups (Kc et al. 2017).

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Discussion/Implications

The five articles selected for this integrative review provide insight regarding how the

timing of umbilical cord clamping affects hemoglobin levels. The researchers PICOT question,

“in infants, what is the effect of delayed cord clamping versus early cord clamping on

hemoglobin levels during the first year of life?”, was answered based on the selected article’s

research findings. The quantitative research studies performed by Abbas et al. (2019), Ertekin et

al. (2015), Kc et al. (2017), Mohammad et al. (2019), and Nouraie et al. (2019) provide various

findings regarding infant outcomes in relation to the timing of umbilical cord clamping. A

positive correlation between DCC and hemoglobin levels was found among infants. The studies

concluded that DCC significantly increases hemoglobin levels in infants within the first year of

life (Abbas et al., 2019; Ertekin et al., 2015; Kc et al., 2017; Mohammad et al., 2019; Nouraie et

al., 2019). The implications of the findings indicate that DCC should performed in all births,

unless the need for resuscitation arises, to provide positive benefits for the infant. Although the

five articles briefly address other outcomes, further research is still warranted (Abbas et al.,

2019; Ertekin et al., 2015; Kc et al., 2017; Mohammad et al., 2019; Nouraie et al., 2019).

Recommendations for future research include analyzing additional fetal outcomes such as the

incidence of necrotizing enterocolitis, incidence of blood transfusions, and the developmental

status. In addition, maternal outcomes should be further assessed to ensure that this intervention

does not negatively impact the mother. Maternal outcomes include post-partum hemorrhage,

hemoglobin and hematocrit levels, anemia, and post-partum depression. While other studies have

briefly addressed these topics, it has not been thoroughly researched. Furthermore, this

researcher recommends further research to analyze the long-term effects of DCC in Infants.

Limitations
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All research poses limitations within itself. These limitations must be addressed in this

integrative review. First, this researcher is considered inexperienced in conducting an integrative

review. The researcher was limited to five studies for this class assignment, which is not

considered an exhaustive review method. The researcher utilized a five-year time frame when

selecting these articles, which limits the generalizability of the PICOT question.

A limitation that this researcher noted is in regard the timing of umbilical cord clamping.

Only two out of the five research articles utilized the same time frame for the DCC group

(Ertekin et al., 2015; Nouraie et al., 2019). Two out of five of the articles utilized the same time

frame for the ECC group (Kc et al., 2017; Nouraie et al., 2019). This poses as a severe limitation,

as the optimal time frame for umbilical cord clamping cannot be determined based on these five

articles. One limitation, stated by Kc et al. (2017), reports that their sample size was not adequate

for their power analysis due to their high attrition rate.

This researcher noted strength in the five article’s study type and design according to the

hierarchy of evidence presented by Fineout-Overholt, Melnyk, Stillwell & Williamson (2010).

This researcher noted that the articles written by Kc et al. (2017), Abbas et al. (2019), and

Nouraie et al. (2019) were randomized control trials which indicates a level II evidence

according to Fineout-Overholt et al. (2010). Level II evidence, along with level I evidence, is

considered the most reliable when supporting a clinical question (Fineout-Overholt et al., 2010).

However, two of the articles written by Mohammad et al. (2019) and Ertekin et al. (2015) are

considered level III evidence by Fineout-Overholt et al. (2010). This may pose as a limitation as

all of the research studies are not considered the most reliable when answering a clinical

question. In addition, the article written by Kc et al. (2017) does not clearly state the validity and
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reliability of the instruments used to collect data. This poses as a limitation, as the accuracy of

the findings may be skewed.

Conclusion

The evidence gathered for this integrative review analyzes the timing of umbilical cord

clamping in relation to fetal outcomes. This topic must be addressed, as this intervention may

provide better outcomes to the infant. This researcher specifically analyzed the effect of delayed

cord clamping on hemoglobin levels in infants. All five articles conclude that DCC significantly

increases hemoglobin levels in infants within the first year of life (Abbas et al., 2019; Ertekin et

al., 2015; Kc et al., 2017; Mohammad et al., 2019; Nouraie et al., 2019). The positive outcomes

that are reported in these articles may facilitate a change in the standard of practice when

performing umbilical cord clamping. Findings in this integrative review further relays the

importance of performing this simple intervention during delivery. In relation to the researchers

PICOT question, “in infants, what is the effect of delayed cord clamping versus early cord

clamping on hemoglobin levels during the first year of life?”, the findings found in the literature

indicate a significant increase in hemoglobin levels when DCC is performed.

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Reference

Abbas, T. R., Elboghdady, A. A., & Mohammed, M. E. (2019). Early versus delayed umbilical

cord clamping in preterm bbirths. The Egyptian Journal of Hospital Medicine, 77(1),

4700–4704. doi: 10.12816/EJHM.2019.45937

Ertekin, A. A., Ozdemir, N. N., Sahinoglu, Z., Gursoy, T., Erbil, N., & Kaya, E. (2015). Term

babies with delayed cord clamping: an approach in preventing anemia. The Journal of

Maternal-Fetal & Neonatal Medicine, 1–4. doi: 10.3109/14767058.2015.1105951

Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Critical

appraisal of the evidence: Part 1. American Journal of Nursing, 110(7), 47-52. doi:

10.1097/01.NAJ.0000383935.22721.9c

Kc, A., Rana, N., Målqvist, M., Ranneberg, L. J., Subedi, K., & Andersson, O. (2017). Effects

of delayed umbilical cord clamping vs early clamping on anemia in infants at 8 and

12 Months. Journal American Medical Association Pediatrics, 171(3), 264. doi:

10.1001/jamapediatrics.2016.3971

Mohammad, K., Tailakh, S., Fram, K., & Creedy, D. (2019). Effects of early umbilical cord

clamping versus delayed clamping on maternal and neonatal outcomes: a Jordanian

study. The Journal of Maternal-Fetal & Neonatal Medicine, 1–7. doi:

10.1080/14767058.2019.1602603

Nouraie, S., Amir Ali Akbari, S., Vameghi, R., & Akbarzadeh Baghban, A. (2019). The effect

of the timing of umbilical cord clamping on hemoglobin levels, neonatal outcomes and

developmental status in infants at 4 months old. Iran J Child Neurol, 13(1), 45–55. doi:

10.22037/ijcn.v13i1.17662
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Pagana, K. D., & Pagana, T. J. (2018). Mosbys manual of diagnostic and laboratory tests. St.

Louis, MO: Elsevier.

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Appendix 1

APA Citation Author APA Citation: Kc, A., Rana, N., Målqvist, M., Ranneberg, L. J., Subedi, K., & Andersson, O. (2017). Effects of
Qualifications Delayed Umbilical Cord Clamping vs Early Clamping on Anemia in Infants at 8 and 12 Months. Journal
American Medical Association Pediatrics, 171(3), 264. doi: 10.1001/jamapediatrics.2016.3971
Author Qualifications: Ashish KC, MD, PHD; Nisha Rana, RN, MPH; Mats Malqvist, MD, PHD: Linda
Jarawka Ranneberg, MD; Kalpana Subedi, MD; Ola Andersson, MD, PHD.

Background/Problem  Roughly 43% of children younger than five years of age have anemia. Which with anemia has
Statement associated neurodevelopment impairments, cognitive impairments, motor impairments and
behavioral impairments. Delaying cord clamping after 3 minutes, compared with clamping the cord
before 60 seconds, would reduce anemia and iron deficiency anemia at 8 and 12 months.

Conceptual/theoretica  No framework was identified.

l Framework

Design/  Randomized clinical trial

Method/Philosophical  Comparison of hemoglobin and ferritin levels from individuals in the early cord clamping and
Underpinnings individuals in the delayed cord clamping. Levels were checked at birth, 8 months and 12 months.

Sample/  540 women from Paropakar Maternity and Women’s Hospital who had an uncomplicated
Setting/Ethical pregnancy, no complication upon admission to the hospital, no clinical history of medical
Considerations conditions, expected vaginal delivery, gestational age of 34-41 weeks and a singleton pregnancy.
240 women were selected for each allocated group.
 Obtained approval from the institutional review board of the hospital and the ethical review board of
Nepal Health Research Council.
Major Variables  Early cord clamping, which means clamping the umbilical cord at less than 60 seconds.
Studied (and their  Delayed cord clamping, which means clamping the umbilical cord greater than 180 seconds.
definition), if  Primary: Hemoglobin levels, Anemia (which is defined in this study as a hemoglobin level less than
appropriate 11.0 g/dL).
 Secondary: Ferritin, Iron-deficiency anemia (which is defined in this study as both hemoglobin and
ferritin levels below the normal range).
 Other secondary variables that are described in separate supplemental reports: Bilirubin levels,
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breast-feeding, morbidity during the first six months of life
Measurement  Venous blood sample (2 ml) collected from a 3- mL syringe. The specimen was then transferred into
Tool/Data Collection an anticoagulant-treated vial where it was stored at room temperature and analyzed the same day. A
Method hematology analyzer was used for hemoglobin analysis and an immunoassay system was used for
ferritin analysis.
 For the allocated procedure, a surveillance officer measured the time of delivery to cord clamping
using a stopwatch.
Data Analysis  Utilized an unpaired 2-tailed t test for variables with normal distribution. Categorical variables were
compared between groups using the Fisher exact test. Ferritin concentration was log 10 transformed
for analysis. If follow-up data was imbalanced between treatment groups and significantly correlated
with primary and secondary outcomes, a multivariate analysis of variance and logistic regression
analysis was performed to control for the imbalance.

Findings/Discussion  At 8 months postpartum, the infant’s mean hemoglobin level was 0.2 g/dL higher in the delayed
cord clamping group. At 12 months postpartum, the infant’s mean hemoglobin level was 0.3 g/dL
higher among the DCC group.

Appraisal/Worth to  By delaying cord clamping, the incidence of infant anemia at 8 and twelve months will be
practice significantly reduced.

APA Citation Author  APA Citation: Nouraie, S., Amir Ali Akbari, S., Vameghi, R., & Akbarzadeh Baghban, A. (2019).
Qualifications The effect of the timing of umbilical cord clamping on hemoglobin levels, neonatal outcomes and
developmental status in infants at 4 months old. Iran J Child Neurol, 13(1), 45–55. doi:
10.22037/ijcn.v13i1.17662
 Authors: Sohelia Nouraie Msc (Department of Midwifery, School of Nursing and Midwifery,
Shahid Behesti Univeristy of Medical Sciences). Sedigheh Amir Ali Akbari, PhD (Department of
Midwifery, School of Nursing and Midwifery, Shahid Behesti Univeristy of Medical Sciences).
Alireza Akbarzadeh Baghban PhD (Proteomics Research Center, Department of Basic Sciences
School of Rehabilitation, Shahid Behesti University of Medical Sciences). Roshanak Vameghi MD
(Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation
Sciences).
Background/Problem  Despite the tremendous amount of evidence supporting delayed cord clamping, early cord clamping
Statement
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is still considered the standard of care in the United States. Delayed cord clamping is known to help
stabilize blood circulation, decrease the incidence of blood transfusions and intraventricular
hemorrhage in premature infants.
Conceptual/theoretica  No framework identified.
l Framework

Design/  . Randomized clinical trail

Method/Philosophical  Comparison of hemoglobin levels, neonatal outcomes and development status in the delayed cord
Underpinnings clamping group and early cord clamping group at birth and 4 months.

Sample/  400 infants from Isfahan University of Medical Sciences and Health Services in Isfahan Iran.
Setting/Ethical  Study was approved by The Ethics Committee of Shahid Beheshti Univserity of Medical Sciences
Considerations with the code SBMU. This study was registered in the Iranian Registry of Clinical trial with the code
of IRCT201702066807N19. Informed consent was collected on all participants.
Major Variables  Delayed cord clamping group, which is defined as cord clamping within 90 to 120 seconds
Studied (and their following delivery.
definition), if  Early cord clamping group, which is defined as cord clamping no later than 60 seconds following
appropriate delivery.
 Hemoglobin levels
 Development status at four months by using the Ages and Stages Questionaire (ASQ)
 Jaundice
 Need for phototherapy
Measurement  Venous blood samples were taken from the umbilical cord at birth and transferred to the lab for
Tool/Data Collection measurement of the hemoglobin level. All tests were performed by the a laboratory technician using
Method the same device.
 The Ages and Stages Questionaire (ASQ) was used to examine developmental status in all infants at
four months of age.
 Data collection tools consisted of information sheets which included a variety of different aspects
such as demographic, medical, pregnancy and childbirth data and forms associated with the
eligibility criteria and infants’ birth profile.
Data Analysis  Data that was obtained were analyzed using the SPSS version 19.
 No alpha identified.
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Findings/Discussion  The mean level of hemoglobin at birth was significantly higher in the delayed cord clamping group;
however, the infants in this group had a developed jaundice more frequently. There were no
significant differences between the two groups need for phototherapy related to jaundice. In delayed
cord clamping group, the ASQ showed increased problem-solving skills which was the only aspect
that differed from the early cord clamping.
Appraisal/Worth to  This article supported the stance that delayed cord clamping significantly increases hemoglobin at
practice birth. There was no difference between the need for phototherapy between both groups. The article
concluded that delayed cord clamping had no significant differences developmentally with the
exception of problem-solving skills.

APA Citation Author  APA Citation: Abbas, T. R., Elboghdady, A. A., & Abdel Samea Mohammed, M. E. (2019). Early
Qualifications versus delayed umbilical cord clamping in preterm bbirths. The Egyptian Journal of Hospital
Medicine, 77(1), 4700–4704. doi: 10.12816/EJHM.2019.45937
 Authors: Tarek Ramadan Abbas, Adel Aly Elboghdady, Mohammed Elnady Abdel Samea
Mohammed. The article states that all Authors are Faculty of Medicine at Al-Azhar University
Department of Obstetrics and Gynecology.

Background/Problem  Infants considered pre-term are at a higher risk of cognitive and motor delay. “Hypovolemia
Statement secondary to immediate cord clamping, may be disruptive to the developing brain resulting in
subsequent minor delay”
Conceptual/theoretica  No framework identified.
l Framework

Design/  Prospective randomized controlled study

Method/Philosophical  Comparison of hemoglobin and hematocrit at 4 hours of age, 12 hours of age, day 3 and day 7 in the
Underpinnings early cord clamping group and delayed cord clamping group.

Sample/  100 pregnant patients at Al-Azhar University Maternity Hospital. 50 were placed in the early cord
Setting/Ethical clamping group and 50 in the delayed cord clamping group.
Considerations  Approved by the ethics committee in Al-Azhar University Hospitals. Informed written consent was
completed by all participants.
Major Variables  Immediate (early) cord clamping group, which consisted of clamping the cord within 15 seconds
Studied (and their from delivery.
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definition), if  Delayed cord clamping, which consisted of clamping the cord beyond 30 seconds to 45 seconds.
appropriate  Hemoglobin levels
 APGAR scores
 Respiratory distress syndrome
 Arterial Blood Gas
 Bilirubin levels
 Intracranial Hemorrhage with preterm infants
 Blood transfusions
Measurement  Gestational age assessment completed by using LMP or early pregnancy ultrasound.
Tool/Data Collection  Subjects were randomized using 100 opaque consecutively numbers envelopes to divide into two
Method equal groups.
 Neonates were held in a sterile towel or blanket 10 to 15 inches below mothers introitus at vaginal
delivery or below the level of incision on maternal abdomen. Stop watched used to time the cord
clamping when the neonates buttocks were delivered from the vagina or uterus.
 Data was collected by the attending neonatologist.
Data Analysis  Data was analyzed using Statistical Program for Social Science (SPSS) version 20.0.
 Independent samples t-test of significance when comparing between two means
 Mann Whitney U test for two group comparisons in non-parametric data.
 Chi-square test of significance was used to compare proportions between two qualitative parameters.
 Pearson’s correlation coefficient ® test was used when correlating data.
Findings/Discussion  Delayed cord clamping (longer than 30 seconds) in preterm births are associated with higher
hemoglobin and hematocrit levels. Delayed cord clamping is associated with a less need for blood
transfusion compared to immediate cord clamping.

Appraisal/Worth to  Delayed cord clamping should be offered at births as evidence shows that it is associated with higher
practice hemoglobin and hematocrit levels.

APA Citation Author  APA Citation: Ertekin, A. A., Ozdemir, N. N., Sahinoglu, Z., Gursoy, T., Erbil, N., & Kaya, E.
Qualifications (2015). Term babies with delayed cord clamping: an approach in preventing anemia. The Journal of
Maternal-Fetal & Neonatal Medicine, 1–4. doi: 10.3109/14767058.2015.1105951
 Authors: Arif Aktug Ertekin- Department of Health Services employee at Uskudar University.
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Nilufer Nihan Ozdemir- Department of Obstetrics at Zeynep Kamil Women and Children’s Disease
Training and Research Hospital. Zeki Sahinoglu- Department of Perinatology, Clinic of Obstetrics
and Ggynecology. Tugba Gursoy- Department of Pediatrics at Koc Univserity School of Medicine.
Nzan Erbil-Department of Pediatrics at Zeynep Kamil Women and Children’s Disease Training and
Research Hospital. Erdal Kaya – Department of Obstetrics and Gynecology at Bagcilar Traning and
Research Hospital.
Background/Problem  Anemia is important to prevent as it is associated with poor neurodevelopment of the infant. Iron-
Statement deficiency is associated with behavioral and cognitive deficits, impaired motor development and
altered affective responding.
Conceptual/theoretica  No framework identified.
l Framework

Design/  Prospective-case control study

Method/Philosophical  Comparison of hemoglobin, hematocrit, iron and ferritin levels between early cord clamping group
Underpinnings and delayed cord clamping group at birth and two months.

Sample/  74 infants at Zeynep Kamil Maternity and Children’s Disease, Training and Research Hospital.
Setting/Ethical  Study was approved by the Local Ethics Committee.
Considerations

Major Variables  Early cord clamping group, which consists of cord being clamped less than 30 seconds after
Studied (and their delivery.
definition), if  Delayed cord clamping group, which consists of the cord being clamped within 90 to 120 seconds
appropriate after delivery.
 Primary: Hemoglobin levels, hematocrit levels, iron levels and ferritin levels
 Secondary: incidence of maternal blood loss, neonatal respiratory distress, bilirubin levels,
phototherapy needed, neonatal intensive care unit admission and length of hospitalization.
Measurement  When the infants shoulder was exposed during delivery, a stop-watch was used to measure the time
Tool/Data Collection for cord clamping. In both cesarean and vaginal births, the infant was placed on the newborn table
Method where the level of the baby and uterus were similar in both groups. Venous blood was obtained from
double-clamped umbilical cord for sampling in both groups. The blood was collected in EDTA tubes
(BD Vacutainer, Franklin Lakes, NJ) for iron and ferritin. Samples transported to the clinic located
in the hospital where it was analyzed within 15 minutes from obtaining samples. At the second
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months, the same parameters were analyzed from venous sample with the sample method used.
Data Analysis  The Social Sciences for Windows 16.0 version used for statistical analyses. T-test and x 2were used
for comparison of two groups and for statistical significance. Type 1 error was calculated at 5%.

Findings/Discussion  Hemoglobin and hematocrit levels between early cord clamping group and delayed cord clamping
group did not different immediately following delivery. Hemoglobin and hematocrit levels were
significantly higher in delayed cord clamping group at two months of age. Ferritin levels did not
differ between the two groups at any point. Five infants (6.8%) in the early cord clamping group
(group 1) and 2 infants (15.7) in the delayed cord clamping group (group 2) needed phototherapy.
Mean of the maximum bilirubin levels was 17.6 in group 1 and 17.9 in group 2. Only infants who
required phototherapy were subject to serum bilirubin draws.
Appraisal/Worth to  Preterm births and term births, delayed cord clamping should be encouraged. Delayed cord clamping
practice had no effect at birth regarding hemoglobin and hematocrit levels; however, it has significant effects
on the hemoglobin, hematocrit, and iron levels at the second month of life without any serious
complications.

APA Citation Author  APA Citation: Mohammad, K., Tailakh, S., Fram, K., & Creedy, D. (2019). Effects of early
Qualifications umbilical cord clamping versus delayed clamping on maternal and neonatal outcomes: a Jordanian
study. The Journal of Maternal-Fetal & Neonatal Medicine, 1–7. doi:
10.1080/14767058.2019.1602603
 Authors: Khitam Mohammad (Maternal and Child Health Nursing and Midwifery Department,
Faculty of Nursing, Jordan University of Science and Technology). Suha Tailakh (Department of
Maternal and Child Health Nursing, Faculty of Nursing, Jordan University of Science and
Technology). Kamil Fram (Department of Obstetrics and Gynaecology, University of Jordan). Debra
Creedy (Maternal. Newborn and Families Research Collaborative, Menzies Health Institute
Queensland, Griffith University).
Background/Problem  The World Health Organization no longer supports early cord clamping of the active management of
Statement the third stage of labor. This study was conducted to evaluate the effect of early vs delayed cord
clamping on maternal and neonatal outcomes.
Conceptual/theoretica  No framework identified.
l Framework

Design/  Quasi-experimental design.

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Method/Philosophical  Comparison of hemoglobin, bilirubin, APGAR and admission to NICU after 12 hours following
Underpinnings delivery and day 3 of birth in the delayed cord clamping group and early cord clamping group.
 Comparison of mothers’ hemoglobin level after 12 hours following delivery in the delayed cord
clamping group and early cord clamping group.
Sample/  128 women and infants who were admitted to Jordan University Hospital.
Setting/Ethical  Ethical approval was granted from the Institutional Review Board at the Jordan University of
Considerations Science and Technology and the hospital. Informed consent was obtained for all participants.

Major Variables  Delayed cord clamping group, which is when the cord is clamped the cord greater than 90 seconds
Studied (and their following delivery.
definition), if  Early cord clamping group, which is when the cord is clamped before 30 seconds of delivery.
appropriate  Newborn hemoglobin levels, maternal hemoglobin levels, bilirubin levels and APGAR scores.

Measurement  Hemoglobin was obtained by measurement of capillary finger sticks in mothers and heel-stick
Tool/Data Collection samples from newborns; the samples were assayed by Hemocue 201+. Newborn bilirubin was
Method measured using Bilicheck. Trained nurses who worked in nursey or postpartum conducted the data
collection.
 Newborn bilirubin was obtained by a venous sample taken by a pediatric resident on day 3 of life.
Sample was taken to the laboratory at Jordan University Hospital.
Data Analysis  Data was analyzed using the Statistical Package of Social Science (SPSS) version 25. Descriptive
statistics were used to describe participants characteristics.
 T-test and chi-square were utilized to compare the mean difference between the two groups.
 Alpha level of 0.05 was used for all statistical tests.

Findings/Discussion  In this study, delayed cord clamping is associated with higher hemoglobin levels among newborns
after 12 hours of life. There were no differences between the groups on any other variable that was
assessed (bilirubin, admission to NICU, APGAR scores, mothers hemoglobin level).
Appraisal/Worth to  This study supported that delayed cord clamping increases newborn hemoglobin level.
practice